Laryngopharyngeal Reflux

What is LPR and LSN?: Laryngopharyngeal Reflux Disease (LPR or airway reflux) develops when stomach acid, bile and pepsin travels up into your throat and beyond. These may irritate the mucus membranes of the upper airways causing microtrauma, inflammation, mucosal thickening, and increased awareness of our normal healthy, sticky, dry mucus. This may lead postnasal drip, globus sensation, throat clearing, cough and voice changes. Most also experience “heartburn and acid brash”, "regurgitation" or “indigestion”, but several patients do not have these complaints. Some of these symptoms may be caused by indirect injury from inflammation reflexes triggered by activation of the vagal nerve in the lower oesophagus. It is not entirely clear with the evidence currently available whether reflux of gastric contents above the oesophagus directly injures the larynx and sinonasal mucosa, whether reflux events cause vagally-mediated neuroinflammatory changes, or if it is a combination of both of these factors.  Laryngeal sensory neuropathy (LSN) which may develop after a virus (post-viral vagal neuropathy is an alternative diagnosis), toxin or trauma or unknown cause may, independent of reflux, trigger identical symptoms. Both LPR and LSN may exist together and obstructive sleep apnoea may worsen both. With careful treatment, it is usually reversible.

• post-nasal drip, sensation of excessive mucus drainage down the back of the throat or "phlegm catching" in the throat
• "globus sensation": "lump in the throat", burning, raw, tickling, dry sore but not painful throat around or below voice box that disappears at meal times;  "constriction", "choking", feeling of something caught in the throat (as if a "hair", "crumb" or "apple peel")
• throat clearing
• hoarseness
• chronic cough
• nocturnal asthma
• difficulty swallowing
• prolonged vocal warm-up (for singers) or voice fatigue
• loss of the high end of the vocal rang
• ear pressure, belching, and halitosis

DIAGNOSIS OF LPR/LSN: There is no perfect test to diagnose LPR and we need more research. Usually patients are given the diagnosis LPR with compatible symptoms,  objective test evidence of airway reflux and after their voice box or throat is found irritated or swollen and sinister or alternative causes have been excluded. These changes may have been noted by an ENT surgeon using a rigid or flexible telescope called laryngoscopy or nasendoscopy, or by a gastroenterologist during a gastroscopy. However, the diagnosis can often be difficult. Throat and voice box changes are commonly seen in healthy "non-refluxers" and as a normal variation. Other non-LPR causes for these symptoms or throat changes are common. Laryngopharyngeal inflammation from overuse or vocal strain, dryness, upper respiratory tract infection, habituated behavioural trauma, allergy is also common and will usually settle with time often without treatment. It is important to carefully exclude many confounding factors associated with laryngopharyngeal complaints (chronic laryngopharyngitis due to tobacco, alcohol, allergy, infections, asthma inhalers, environmental irritants, poor vocal hygiene, muscle tension dysphonia), along with asthma, chronic rhinosinusitis and postnasal drip, angina, psychological distress and more generalised gut motility problems like gastro-oesophageal neuromuscular disorders and slow transit constipation. It's not uncommon to have more than one diagnosis.

Successful response to a treatment trial helps the diagnosis. The treatments aim both to reduce acid and bile refluxing from the stomach into the larynx and also to settle hypersensitive misfiring nerves which may cause neuroinflammatory changes in your pharynx and larynx and oesophagus. There is no test for LSN or sensory nerve damage. Usually the only clue to LSN is a sudden onset after a viral illness or surgery and good relief with neuropathy treatment. Rarely there may be a muscle problem with the uvula or vocal cords not moving properly. Your symptoms along with this swelling and inflammation will eventually resolve with treatment, although it may take a few months.

Appreciate and accept the genius of the sticky, "fly paper-like" antibody-rich mucus without which you'd be dead. Understand that, while your awareness of this mucus might increase or decrease over time, you will never stop the 1-1.5 litres produced in the upper airways every day, swept backwards every few minutes and swallowed into the stomach twice a minute even in sleep.

If treatment has not worked after several months on PPIs, and LPR is still suspected, you may undergo multichannel intraluminal impedance and pH monitoring (MII-pH). This involves placing a small tube (catheter) through your nose and down into your swallowing passage (oesophagus). The catheter is worn for a 24-hour period. The pH probe measures the amount of acid that refluxes into your throat but only the impedance testing may detect non-acid reflux or some aerosolized molecules.  You will asked to keep a symptom diary which will be used to see if there is a link between your symptoms and measured reflux episodes. This test is often not necessary and may under- or over-diagnose LPR (with some false negatives and positives). In one  study, more than 60% of patients suspected to have LPR were found not to have gastroesophageal reflux disease on MII-pH. Despite argument and little consensus among experts internationally on its validity, pH and impedance testing can provide important information in certain cases. The nuclear medicine reflux study and oral salivary pepsin test (or Peptest®) are sometimes ordered and these share with the MII-pH a lack of consensus from experts on validity and what is a normal or abnormal test. With some patients, a gastroscopy may be needed to examine the upper digestive tract for pre-malignant oesophageal changes, hiatus hernia or to consider gastroparesis.

TREATMENT OF LPR/LSN: Most of the time, LPR and LSN is well controlled with lifestyle changes and medications such as proton pump inhibitors (PPI’s) for LPR and neuropathy medications for LSN like amitryptiline, gabapentin and pregabalin. Reassurance, explanations of the condition, voice retraining with a speech therapist and behavioural therapy to break any cough-irritation cycle, throat clearing or dry swallow habits may all be needed. Laxatives and bowel training will be important if constipated. In the rare event of severe LPR resistant to simple measures, proven on a pH probe study, surgery may be needed, particularly if there are oesophageal symptoms. The surgery is called a Laparoscopic Nissen Fundoplication and it needs careful consideration risks and benefits.

Ten secrets to treating LPR

If postural or night time symptoms predominate are decreasing the evening meal size and fasting for several hours before retiring is important and, if obese, weight loss through appropriate changes to diet and lifestyle. Some have clear food and drink triggers which . There will be some who try everything without benefit: losing 5-10kg, decreasing potential food and drink triggers which irritate the oesophagus or transiently lower the pressure in the lower oesophagus' antireflux valve and avoiding night time meals . However, it is important that you work out what worsens your reflux and some of these changes may work:

1. REDUCE CAFFEINE AND ACIDIC DRINKS, CHOCOLATE AND MINT. This includes coffee, tea, and caffeinated soft drinks. Soft drinks such as Coke and Pepsi are acidic, (pH of 2.3), and the carbonation leads to belching and further reflux of acid into the throat. Other acidic juices (orange, grapefruit, lime, cranberry) and tomato can be irritating for some. Chocolate and mint chemically cause the lower oesophageal sphincter to loosen, triggering acid reflux in others

2. REDUCE ALCOHOL, especially in the late evening and before bedtime.

3. QUIT SMOKING, this includes nicotine patches increase reflux in many decreasing the function of the lower oesophageal sphincter valve and delaying the stomach emptying

4. REDUCE FRIED, FATTY or WINDY VEGETABLES  from YOUR DIET. A low-fat diet is a good way to avoid reflux for many. Windy vegetables like the cruciferous group (cabbage, Brussel sprouts, broccoli), Onions and garlic are notorious for causing reflux in others.

5. REDUCE highly refined, highly processed, sugary and low fibre foods including junk food. Favour a diet high in complex carbohydrates and whole foods which include the skin of fruits and vegetables, whole grains, seeds, and naturally high fibre foods. If you are seeking more direction consult a dietitian and review the below diet plan. Lechien et al got some good results with this alkaline, protein, low fat diet (see below)